11786 SW BARNES RD, STE 360

PORTLAND, OR 97225 (503) 646-1811

www.cedarcreekdentistry.com

Directions to the Barnes Road Professional Campus

Our office is located in the Barnes Road Professional Campus in southwest Portland on S.W.

Barnes Road two blocks west of S.W. Cedar Hills Blvd. Please call our office for directions if

you are unfamiliar with the area.

Coming from Portland on Sunset Highway (26): Take Exit 68 (Cedar Hills Blvd) and

turn right onto SW Cedar Hills Blvd. At the first light, turn left onto SW Barnes Rd. Go

approximately 0.3 miles and just past SW 117th/Sunset Medical Clinic. Get into the left turn

lane and turn into the Barnes Road Professional Campus. Our building (11786) is near the

back of the campus behind the parking structure.

Coming from the South on Highway (217): At the North end of Hwy 217, take the

Barnes Road exit and then stay in the left lane to head West on Barnes Road. Travel on

Barnes Road approximately 0.3 miles past Cedar Hills Blvd and just past SW 117th/Sunset

Medical Clinic. Get into the left turn lane and turn into the Barnes Road Professional

Campus. Our building (11786) is near the back of the campus behind the parking structure.

Coming from the West on Sunset Highway (26): Take Exit 68 (Cedar Hills Blvd).

At the bottom of the ramp turn left on SW Cedar Hills Blvd. At the second light, turn left

onto SW

Barnes Road. Go approximately 0.3 miles and just past SW 117th/Sunset Medical Clinic. Get

into the left turn lane and turn into the Barnes Road Professional Campus. Our building

(11786) is near the back of the campus behind the parking structure.

REGISTRATION FORM

Patient Name: ________________________________________________ Last M.I. First

SS#:_____________________________ DL#:____________________ Sex: Male Female Marital Status: Single Married Divorced Widowed Partnered Spouse/Guardian Name: Home Address: _________________________________________ Home Phone: ______________________ Cell: ________________________ Work:

Email Address: What is the best way to contact you? � Home � Cell � Email � Work Employer Name: ________________________________________Spouse/Guardian Name: Who may we thank for referring you?

Name of person responsible for account: _________________________________DOB: ______________ Age: _______ SS#:_______________________ Address: __________________________________________ Employer Name: _______________________________________

Phone:

Subscriber’s Name: _______________________________________ DOB: _____________ SS#:__________________________Insurance Company: __________________________________________Ins Phone#:____________________________ Employer’s Name: _________________________________

Subscriber’s Name: _______________________________________ DOB: _____________ SS#:__________________________Insurance Company: __________________________________________Ins Phone#:____________________________ Employer’s Name: _________________________________

I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the dental office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payers and/or other health care professionals as is beneficial for payment or dental care.

Thank you for expressing your confidence in choosing our practice! We look forward to assisting you with your dental needs. Please fill out this form in ink only. If you have any questions regarding this form do not hesitate to ask for assistance. We will be happy to help.

Do you have Secondary Dental Insurance? ���� YES ���� NO

PRIMARY DENTAL INSURANCE INFORMATION

RESPONSIBLE PARTY

Birth Date:

City/State/Zip:

Occupation:

Phone:

City/State/Zip:

Work Phone:

ID#:

Relationship:

Signature of Parent/Guardian Date

*Please list an Emergency Contact not living with you. Name: Relationship:

ID#:

Relationship:

Group #:

Ins Address:

Work Phone:

Group #:

Ins Address:

Work Phone:

Relationship:

Patient Name: _______________________________________________ DOB: _________________

Check (�) if you have or have had problems with any of the following:

AIDS/HIV Positive Yes No Fainting or dizziness Yes No Respiratory Disease Yes No

Anemia Yes No Fibromyalgia Yes No Rheumatic Fever Yes No

Angina Yes No Glaucoma Yes No Scarlet Fever Yes No

Anxiety Yes No Headaches Yes No Shortness of Breath Yes No

Arthritis, Rheumatism Yes No Heart Attack Yes No Seizures Yes No

Artifical Heart Valves Yes No Heart Murmur Yes No Sinus Trouble Yes No

Artifical Joints, Date _______ Yes No Heart Disease Yes No Stroke Yes No

Asthma or Hay Fever Yes No Hemophilia Yes No Swollen Feet or Ankles Yes No

Bleeding abnormally, with Hepatitis Type ______ Yes No Swollen Neck Glands Yes No

extractions or surgery Yes No Herpes Yes No Thyroid Problems Yes No

Blood Disease Yes No High Blood Pressure Yes No Tonsillitis Yes No

Blood Transfusion Yes No Jaundice Yes No Tuberculosis Yes No

Cancer Therapy Yes No Jaw Pain Yes No Ulcer Yes No

Chemical Dependency Yes No Kidney Disease Yes No Venereal Disease Yes No

Chemotherapy Yes No Leukemia Yes No Weight Loss, unexplained Yes No

Circulatory Problems Yes No Liver Disease Yes No Have you had any serious

Congenital Heart Lesions Yes No Low Blood Pressure Yes No illness or surgeries? Yes No

COPD Yes No Measles or mumps Yes No If Yes, describe:

Cortisone Treatments Yes No Mitral Valve Prolapse Yes No

Diabetes, Type _____ Yes No Neurological Problems Yes No

Emphysema Yes No Pacemaker Yes No

Endocarditis Yes No Psychiatric Care Yes No

Epilepsy Yes No Radiation Treatment Yes No

Cortisone or Other Steroids Insulin or Diabetes Medications

Anesthetics, General Coumadin, Heparin, Warfarin Sedatives or Tranquilizers

Antacids or other blood thinners Sleeping Pills (Barbiturates)

Anti-anxiety Medications Dilantin Thyroid Medication such as Synthroid,

Anti-depressants Diuretics (water pills) Levoxyl or Levothyroxine

Antihistamines Fen-phen (Lonimin, Adipex, Fastin, Tylenol (Acetominophen)

Daily Aspirin Regimen Phentermine, Pondimin, Fenfluramine,

Birth Control Pills Redux, Dexfenfluramine)

Blood Pressure Medications Heart Medications such as Digoxin, Tobacco Yes No

Codeine, Demerol Nitroglycerin or Digitalis Packs per day ________

Ibuprofen (Motrin) Women: Are you pregnant? Yes NoNursing? Yes No

List the other medications you are curretnly taking and what condition you are taking them form Include vitamins, supplements, herbs and over the counter medications.

Medication Prescribing Doctor

Allergies: Acrylic Aspirin Clindamycin Codeine Latex

Local Anesthetics Metal Penicillin Sulfa Drugs

Other If yes, please explain:

Do you have any other health needs you should bring to our attention?

Medications routinely used in dental treatment may interact with both prescription and a number of illegal street drugs. Check (�) themedications you are presently taking, medications you have taken in the past, or medications you have had an adverse reaction to:

Condition

Check (�) your current use of:

Pharmacy Phone

MEDICAL HISTORY

Pharmacy Name

Please print name of Patient, Parent, Guardian or Personal Represtative

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health.

Signature of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

Date

Presently Taken in History ofTaking the Past Reaction

Presently Taken in History ofTaking the Past Reaction

Presently Taken in History ofTaking the Past Reaction

Patient Name:

Previous Dentist:

Why did you leave your previous dentist?

Check (�) if you have or have had problems with any of the following:

Bad Breath Yes No Chew on one side of mouth Yes No

Bleeding gums Yes No Tobacco use Yes No

Gums swollen or tender Yes No Chewing on foreign objects Yes No

Sores, blisters, growths on lips or mouth Yes No Fingernail biting Yes No

Burning sensation on tongue Yes No Thumb sucking Yes No

Biting cheeks or lips Yes No Tongue thrusting Yes No

Dry mouth Yes No Pain on brushing teeth Yes No

Mouth breathing Yes No Loose or broken teeth Yes No

Chewing Yes No Loose or broken fillings Yes No

Swallowing Yes No Food collection between the teeth Yes No

Talking Yes No Sensitivity to cold Yes No

Prominent gag reflex Yes No Sensitivity to hot Yes No

Snoring Yes No Sensitivity to sweets Yes No

Periodontal treatment Yes No Sensitivity when biting Yes No

Pyorrhea or trench mouth Yes No Stained teeh Yes No

Orthodontic Treatment Yes No Grinding or clenching teeth Yes No

Wisdom teeth extracted Yes No Clicking or popping jaw Yes No

Bite problems Yes No Jaw pain or fatigue Yes No

Missing teeth Yes No Opening or closing jaw Yes No

Shifting position of teeth Yes No Pain around ear Yes No

How often do you brush? How often do you floss?

How often do you have your teeth cleaned?

How often do you change toothbrushes?

What is your goal for dental treatment today?

Are you in discomfort today? Yes No

Are you pleased with the appearance of your teeth? Yes No If no, please explain:

Do you like your smile? Yes No If no, please explain:

Does dental treatment make you nervous? Yes No If yes, please explain:

Have you been pleased with your previous dental care? Yes No

Have you ever had a bad experience in a dental office? If so, please explain:

How can we help improve your teeth and smile?

Signature of Patient Date

PATEINT GOALS

DENTAL HISTORY

DOB:

Phone:

Date of Last X-Rays: Date of Last Appt:

Cedar Creek Dental Cristina L. Rust, D.M.D.

11786 SW Barnes Rd Ste 360 | PORTLAND OR, 97225 | (503) 646-1811

Financial Agreement

Thank you for choosing Cedar Creek Dental for your dental needs. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care easy and manageable for our patients by offering several payment options.

Available Options:

- Cash, Check, Visa, MasterCard, or Discover Card

- In office payments extended over 3-months via automatic credit card withdrawal

- Outside financing

Please note:

Cedar Creek Dental requires payment at time of service.

For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment, however your ESTIMATED portion is due at the time of the appointment. Please note we can only ESTIMATE what your insurance will remit as your insurance is a contract benefit between you, your employer, and the insurance company. We are happy to assist you in billing your insurance and will do our best to maximize your benefits; however, you are ultimately responsible for the cost of treatment performed.

Please indicate method of payment you prefer:

( ) Payment in full

( ) Automatic credit card withdrawal

( ) Financing plan upon approval

We charge 18% interest on all past due accounts, $50.00 for appointments missed or cancelled without a minimum of 24 hour notice, and $35.00 for any returned check.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

Patient, Parent or Guardian Signature Date

Patient Name (Please Print)

Cedar Creek Dental Cristina L. Rust, D.M.D.

11786 SW Barnes Rd Ste 360 | PORTLAND OR, 97225 | (503) 646-1811

At Cedar Creek Dental we are determined to show each and every patient an outstanding experience. It’s always been our belief that your time is valuable, therefore we have one theory about scheduling, you deserve our undivided attention. For this reason, we do not double-book like other practices and accept unscheduled appointments in the event of an emergency ONLY. When we schedule a dental visit, that time is yours. It belongs to you. So when cancellations happen, sometimes as little as an hour ahead of time, we feel like we have been stood up for a very important appointment, an appointment that has everything to do with your on-going dental health. Of course flat tires, sick children, and family emergencies do happen and we understand, but the cost of needlessly missed appointments is borne by us all. Our staff has made a promise, professionally and personally, to give you the concern, respect and care that makes our office a comfortable and pleasant place to visit. We ask our patients to give us at least 24 hours notice if they cannot keep an appointment. We try very hard to keep our schedule and hope our patients try too. If the 24 hour notice is not upheld and there is either a no-show to the scheduled appointment or “less than” 24 hours notice, we may charge your account $50.00 or request a deposit of 50% to be paid in advance to reserve your next appointment. Our feeling is this, your dental health is important and it deserves respect ~ yours and ours. I have read and acknowledge the above statement. Date: __________________________________________________________________ Signature: ______________________________________________________________ If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form: Relationship to patient: ___________________________________________________ Print Name: ____________________________________________________________ Source of Authority: _____________________________________________________

Cedar Creek Dental Cristina L. Rust, D.M.D.

11786 SW Barnes Rd Ste 360 | PORTLAND OR, 97225 | (503) 646-1811

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION Section A: Patient Giving Consent Name: _________________________________________________________ Address: _______________________________________________________ _______________________________________________________________ Telephone: _________________________ Email: ______________________ Social Security #: ___________________________ DOB: ________________ Section B: PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our notice, at any time by contacting: Contact person: Amanda Noyes Address: 11786 SW Barnes Rd., Ste. 360

Portland, Oregon 97225 Telephone: (503) 646-1811 Fax: (503) 924-1698 E:mail: Office@cedarcreekdentistry.com

Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke the consent. Signature: I, ____________________________________________________________, have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that by signing this consent form I am giving my consent to use and disclose my protected health information to carry out treatment, payment activities and health care operations. Signature: _______________________________________________________________ Date: ___________________________________________________________________ If this consent is signed by a personal representative on behalf of the patient, complete the following: Personal representative name: _______________________________________________ Relationship to Patient: ____________________________________________________

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

Revocation of consent: I revoke my consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations. I understand that revocation of my consent will not affect any action you took in reliance on my consent before you received this written notice of revocation. I also understand that you may decline to treat or continue to treat me after I have revoked my consent. Signature: ________________________________________ Date: _________________

© 2010 American Dental Association. All Rights Reserved.

Cedar Creek Dental

Cristina L. Rust, D.M.D.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give

you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the

privacy practices that are described in this Notice while it is in effect. This Notice takes effect 1/11/2013, and will remain in effect until we

replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by

applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health

information that we maintain, including health information we created or received before we made the changes. Before we make a significant

change in our privacy practices, we will change this Notice and provide the new Notice at our practice location, and we will distribute it upon

request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice,

please contact us using the information listed at the end of this notice.

Your Authorization: In addition to our use of your health information for the following purposes, you may give us written authorization to use

your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time.

Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written

authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

___________________________________________________________________

Uses and Disclosures of Health Information

We use and disclose health information about you without authorization for the following purposes.

Treatment: We may use or disclose your health information for your treatment. For example, we may disclose your health information to a

physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. For example, we may send

claims to your dental health plan containing certain health information.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. For example,

healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare

professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or

credentialing activities.

To You Or Your Personal Representative: We must disclose your health information to you, as described in the Patient Rights section of this

Notice. We may disclose your health information to your personal representative, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a

family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If

you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or

disclosures. In the event of your absence or incapacity or in emergency circumstances, we will disclose health information based on a

determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your

healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best

interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written

authorization.

© 2010 American Dental Association. All Rights Reserved.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Public Health and Public Benefit: We may use or disclose your health information to report abuse, neglect, or domestic violence; to report

disease, injury, and vital statistics; to report certain information to the Food and Drug Administration (FDA); to alert someone who may be at

risk of contracting or spreading a disease; for health oversight activities; for certain judicial and administrative proceedings; for certain law

enforcement purposes; to avert a serious threat to health or safety; and to comply with workers’ compensation or similar programs.

Decedents: We may disclose health information about a decedent as authorized or required by law.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We

may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security

activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an

inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail

messages, postcards, or letters).

______________________________________________________________________________

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies

in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in

writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end

of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. We will charge you a reasonable

cost-based fee for the cost of supplies and labor of copying. If you request copies, we will charge you $0.50 for each page, $0.00 per hour for

staff time to copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will

charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your

health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information

for purposes other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before April 14,

2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to

these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. In most

cases we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in certain

circumstances where disclosure is required or permitted, such as an emergency, for public health activities, or when disclosure is required by

law). We must comply with a request to restrict the disclosure of protected health information to a health plan for purposes of carrying out

payment or health care operations (as defined by HIPAA) if the protected health information pertains solely to a health care item or service for

which we have been paid out of pocket in full.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means

or at alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide

satisfactory explanation of how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why

the information should be amended. We may deny your request under certain circumstances.

Electronic Notice: You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on our

Web site or by electronic mail (e-mail).

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health

information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us

communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end

of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the

address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or

with the U.S. Department of Health and Human Services.

Contact Officer: Amanda Noyes

Telephone: (503) 646-1811

Fax: (503) 924-1698

E-mail: office@cedarcreekdentistry.com

Address: 11786 SW Barnes Rd., Ste. 360

Portland, Oregon 97225-5930

Cedar Creek Dental Cristina L. Rust, D.M.D.

11786 SW Barnes Rd Ste 360 | PORTLAND OR, 97225 | (503) 646-1811

2013-2015 Medicare Private Contract

I Cristina L. Rust, have not been excluded from Medicare under (1128), (1156), or (1892) 1892 of the Social Security Act. I, ______________________________________ or my legal representative, accepts full responsibility for payment of charges for all services furnished by Cedar Creek Dental. I, ______________________________________ or my legal representative, agrees not to submit a claim to Medicare or to ask Cedar Creek Dental to submit a claim to Medicare. I, ______________________________________ or my legal representative, understands that Medicare payment will not be made for any items or services furnished by Cedar Creek Dental that would have otherwise been covered by Medicare if there was not a private contract and a proper Medicare claim had been submitted. I, ______________________________________ or my legal representative, enters into this contract with the knowledge that I have the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not opted-out of Medicare, and that I am not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. The expected or known effective date and expected or known expiration date of the opt-out period is 3-13-2013 thru 3-13-2015. I, ______________________________________ or my legal representative, understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.

This contract cannot be entered into by me, __________________________, or by my legal representative during a time when I require emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with 3044.28 of the Medicare Carriers Manuel). I, ______________________________________ or my legal representative, will receive or have received a copy of this contract, before items or services are furnished to me under the terms of this contract. I, Cristina L. Rust will retain the original contract for the duration of the opt-out period. I, Cristina L. Rust will supply CMS a copy of this contract upon request. I, Cristina L. Rust understand that the private contract remains in effect for two years. If I again opt-out of Medicare, I will expediently complete a new contract for each Medicare beneficiary and will expediently submit the appropriate affidavit to all local Medicare carriers. ____________________________________ __________________ Provider’s Signature Date ____________________________________ __________________ Patient’s Signature Date ____________________________________ __________________ Patient’s Legal Representative Signature Date ____________________________________ __________________ Witness Date